Case History Edit
While making out with his girlfriend in his car, Stevie suddenly started suffering from respiratory arrest. His girlfriend called for help and a nearby police officer called an ambulance to rush him to the Princeton-Plainsboro Teaching Hospital emergency room.
The case was referred to Dr. Foreman, who presented it to Dr. House. The patient showed no sign of trauma and had no medical history of asthma or allergies. His EKG and Echocardiogram were normal. He did present with a bloody pleural effusion. A CT scan found no tumor or pneumonia. Dr. Chase thought it was cocaine, but the patient's tox screen was clean. Dr. Cameron noted the clean screen didn't mean he hadn't used drugs, only that he had not done so recently. When Dr. House mentioned a leak, Dr. Foreman thought he was referring to an aneurysm, but if that were the case the patient would be dead by now. However, Dr. House noted it could be a leak in a vein instead of an artery and ordered a veniogram. Dr. Chase noted that drugs could cause leaky veins, so Dr. House ordered an environmental scan.
Stevie was still coughing and in pain and Dr. Foreman couldn't get in contact with his parents to get consent to give him painkillers or do the veniogram. His girlfriend asked why another adult (like her parents) couldn't do it, but Dr. Foreman insisted it had to be Stevie's parents given he was a minor. However, Stevie was more resigned to the matter as he knew his parents were away at a conference. He described the sensation as like having an anvil on his chest. However, Stevie's 02 stats were falling and Dr. Foreman decided to do the procedure despite the lack of parental consent.
During the procedure, Stevie complained his fingers felt wet. Dr. Foreman told him it was just a false sensation - his nerves were just feeling the cold dye they used during the procedure and couldn't tell the difference. Stevie asked if the problem was with his nerves or brain and Dr. Foreman asked if he liked science. Stevie said that he did and said the veniogram looked like a diffusion pattern. Dr. Foreman explained that was because the blood wasn't under pressure like it is in the arteries. Stevie correctly identified Graham's Law as the reason this occurred. Dr. Foreman asked if he was studying physics already, but Stevie said he just liked to read about it. Stevie also realized that any leak that would affect his breathing would have to be in the pulmonary vein, but he couldn't see any problem there and wondered how he could have a bloody effusion without any bleeding.
Dr. Chase and Dr. Cameron went to the address Stevie gave but soon realized they were in the wrong house. When they confronted him about not wanting to contact his parents, he maintained he gave them the correct address and phone number. However, his girlfriend told the doctors that Stevie was a Romani, more colloquially a Gypsy. Dr. Cameron wondered if he had a permanent address and he insisted they did, but that his culture did not allow outsiders to come into their homes and his parents were serious about it. He admitted to using alcohol and marijuana. Dr. Cameron noted that although marijuana couldn't cause bleeding, pesticides could and asked where he got it. His girlfriend admitted he got it for him and told the doctors that Stevie didn't attend school. When he said he was home schooled, she said that he just read a lot of books. Stevie admitted his father was a salesman, not a professor, and that they had recently come home from Chicago in his father's truck.
Dr. Foreman reported the veniogram showed no leak, but Dr. House thought he may have missed it. However, Dr. Foreman also checked the lymphatic system and there were no leaks there either. Dr. Foreman thought it was a deep-vein thrombosis from the truck trip. A clot from that could have made its way to the lungs. He wanted to do an arteriogram to find the clot and break it up with TPA. However, Dr. House still thought it was a leak and ordered blood thinners followed by another veniogram despite the risk of massive internal bleeding.
Dr. Cameron and Dr. Foreman started an arteriogram and Dr. Foreman distracted Stevie by having him name the bones of his arm while they scanned them. However, as they were starting the procedure, Stevie started having intense pain in his abdomen and started moving around. Dr. Cameron wanted to stop the procedure, but Dr. Foreman told her to inject the dye because they may not get another chance. However, the dye would not leave the liver. Dr. Foreman thought it might be a clot in the hepatic vein, but Dr. Cameron noted that no dye at all was coming out, which could only mean liver failure.
The liver failure was being caused by multiple clots in the hepatic vein and Dr. Foreman wondered how the patient could be both bleeding and clotting at the same time. Dr. House thought it may have been blocked by the catheter wire, but Dr. Cameron denied screwing up the procedure. Dr. Chase thought it might be increased pressure in another vein that was slowing the flow of blood, but Dr. Foreman noted there was no cirrhosis or heart failure, so it had to be a clot. Dr. Cameron proposed DIC, but Stevie's platelet count was normal and his prothrombin time was normal. Dr. Chase suggested leukemia but Stevie's CBC was normal. Dr. House thought that leaks from the liver may have formed a mass. Dr. Chase thought perhaps it was a tumor eroding a blood vessel and Dr. Foreman suggested a granuloma could do the same. Dr. House ordered a CT Scan, MRI, sputem test and ACE level.
The team started the MRI. They found a granuloma in his liver, which meant Wegener's disease was most likely. Suddenly, his parents burst into the room and Dr. Foreman insisted they leave until they could finish.
Dr. Foreman found Stevie in his street clothes eating food his parents had prepared. Dr. Foreman took away the food and told him they had to control his environment. Stevie complained he had a burning sensation in his chest, which Dr. Foreman put down to the inflammation typical of Wegener's. His parents arrived with more of Stevie's things and Dr. Foreman confronted them about giving him things like willow bark extract that could cause a medicine interaction. When his girlfriend arrived, his parents tried to throw her out and blamed her for Stevie's illness. All of a sudden, Stevie doubled over in pain and they noticed bleeding from his groin.
Despite the new symptom, Stevie's liver function continued to improve. The bleeding was from a massive hemmorhage in his bladder. However, it still looked like Wegener's, but the treatment was having an adverse effect as well. The other tests had ruled out tuberculosis, sarcoidosis and lymphoma. Dr. Cameron thought it might be cancer, but the scans and blood tests were all negative. They decided to change the treatment, but the alternative, methotrexate, was contra-indicated due to his lung problems. Dr. House suggested immune system modulation with FT28. This would keep the antibodies from affecting his blood vessels, but they would still work everywhere else. Dr. Cameron pointed out FT28 was still experimental. However, it had been used successfully with Crohn's disease and Rheumatoid arthritis.
However, Stevie's father refused consent to an experimental procedure. When Dr. Foreman reported this to Dr. House, they realized they had no other treatment available and asked Dr. Foreman to try again. Dr. Foreman went back to Stevie's room to find his extended family there and told the father he was just there to replace the cyclophosphamide as he requested. He then asked everyone to leave the room so he could bandage Stevie's penis in private. Stevie realized Dr. Foreman was lying as he wasn't bleeding anymore. Dr. Foreman then told Stevie he wanted to give him FT28, but his parents didn't want him too. He explained that the drug had been used successfully for other conditions and Stevie realized that given the fact they were suggesting experimental treatment, that there were no other options. He wanted Stevie to take the FT28 in secret. Stevie was reluctant to trust Dr. Foreman and lie to his parents, but was convinced when Dr. Foreman told him that if the parents found out, he would lose his medical license. Stevie agreed, but before he could take the medication, he started having more abdominal pain. He was rushed into surgery.
The surgery found that Stevie's spleen had burst and that he had other bleeding. The surgeon removed the spleen and sealed the other bleeds. Dr. Foreman took the spleen for biopsy and asked the surgeon not to close until they confirmed the Wegener's so they could still treat him without having to open him up again. However, there were no granulomas in the spleen. The surgeon went to close but Dr. House, who was observing, asked the surgeon to examine the whole small intestine. The surgeon refused because the apparent granuloma in the liver was just a scar, so Dr. House entered the operating room to do it himself. The surgical team could not keep Stevie stable while Dr. House was examining the bowel. Dr. House tried to order a bag of Ringer's lactate, but when the surgical team refused, he ordered Dr. Foreman to do it. However, he found no issues with the small intestine. The surgeon closed the incision. Dr. House realized that FT28 would not have been effective and that the parents were right.
The parents wanted to transfer Stevie to another hospital and would not allow Dr. House to treat him. Dr. Foreman wanted to test for Von Wildebrant's disease. Dr. House wanted to focus on why Stevie was bleeding in some places and clotting in others and they reviewed the symptoms and procedures:
- Lungs - CT Scan, sputem test, two veniograms, one bleed one clot
- Liver - MRI, blood tests, cyclophosphamide, blood in urine (3 units)
- Kidney & Bladder - High resolution CT scan, UA and Urine sediment
- Digestive tract - Ran small intestine, but not the large intestine because there were no symptoms.
Dr. House decided to order a colonoscopy because it was the only place in his abdomen they hadn't looked. However, there didn't appear to be any way the parents would allow it. However, Dr. Foreman realized that Stevie was now in intensive care and the parents couldn't stay in his room all the time. Dr. House distracted the parents while Dr. Foreman, Dr. Cameron and Dr. Chase did the colonoscopy. Stevie's blood pressure started to drop again, indicating more bleeding, but Dr. Chase couldn't find any blood in his colon - it looked normal. All of a sudden, Dr. Foreman spotted something - it was a toothpick.
Dr. Foreman figured Stevie, who like his father kept a toothpick in his mouth most of the time, swallowed one accidentally. Normally, a toothpick wouldn't do any harm as it passed through the digestive tract, but since he was cramped in the back of his car with his girlfriend, it probably pierced the small intestine and entered the lung. From there it worked its way through the liver, bladder and spleen. Once they removed the toothpick, the holes were very small and should heal on their own. It didn't show up on scans because once it absorbs water, it becomes the same density as the surrounding tissue.
Dr. Foreman was impressed with Stevie's knowledge and asked him if he wanted to interview for a lab intern position, but Stevie turned him down because he wanted to work with his family. He noticed none of the doctors working on his case appeared to have any family connections.